Project Abstract: This proposal seeks funding to study the impact of motivational strategies designed by the gaming industry on adherence to a home tele-rehabilitation program designed to improve hand function in persons with stroke. A growing literature suggests that the extended practice of challenging upper extremity tasks can produce measurable changes in hand function in persons with stroke. Current health care delivery systems do not support this volume of directly supervised rehabilitation, making it necessary for patients to perform a substantial amount of activity at home, unsupervised. Unfortunately, adherence to unsupervised home exercise regimens is quite poor in this population, with low motivation levels cited as an important barrier. Several small studies have described higher levels of motivation associated with virtual reality-based rehabilitation than real world exercise. These higher levels of motivation transfer to better adherence to autonomous home exercise for VR-based activities than traditionally presented home exercise but the improved training times still fall short of the volume of training associated with meaningful improvements in hand function. In stark contrast, the average weekly participation time in commercial computer games for healthy adults is two and a half times larger than the participation times for home based virtual rehabilitation. Our goal is to assess the impact of several well-established game design strategies: 1) Scaffolded increases in game difficulty 2) In-game rewards 3) Quests with enhanced narrative. We will utilize these enhancements to study their impact on motivation to perform a tele-rehabilitation- based home exercise program, adherence to the program and changes in hand function subsequent to the program. The proposed study will utilize a system of novel rehabilitation technologies designed to facilitate home exercise performance. Subjects will perform a set of simulated rehabilitation activities supported by a passive exoskeleton and an infrared camera and software that is specifically designed to capture finger movement that will allow subjects to exercise at home. We will investigate: 1) Differences in measures of motivation elicited by motivationally enhanced simulations and un-enhanced control versions.2) The impact of motivational enhancements on actual adherence to a long term tele-rehabilitation program in persons with stroke and 3) The impact of these motivational enhancements on improvements in hand function achieved by the subjects with stroke in this study. This proposal will address a critical gap in modern rehabilitation practice ? adherence to autonomous rehabilitation programs. Patient participation in unsupervised rehabilitation is one of the assumptions underpinning our health care system. This said, none of the data collected to date support that adherence is acceptable and no scientific attention focused on optimizing adherence. The technology and methodology in this proposal are an important first step towards the leveraging extensive research and development done by the computer gaming industry into improved rehabilitation practice that could benefit millions of persons.